RN Appeals Analyst Medicare Part B - CGS

Summary We are currently hiring for an Appeals Analyst to join BlueCross BlueShield of South Carolina. In this role as Appeals Analyst, you will research the substance of complex appeal or retrospective review requests including pre‑pay and post‑payment review appeal requests. Additionally, you will provide thorough clinical review or benefit analysis to determine if the requested services meet medical necessity guidelines. Lastly, you will document decisions within mandated timeframes and in compliance with applicable regulations or standards. Logistics CGS – one of BlueCross BlueShield's South Carolina subsidiary companies. This position is full time (40 hours/week) Monday‑Friday 8:00‑4:30 PM CST and will be View email address on click.appcast.io or On‑site at One Century Plaza, Nashville TN. What You Will Do Document the basis of the appeal or retrospective review in an accurate and timely manner and in accordance with applicable regulations or standards. Perform thorough research of the substance of service appeals by both member and provider based on clinical documentation, contractual requirements, governing agencies, policies and procedures, while adhering to confidentiality regulations regarding protected health information. Perform appeal and retrospective reviews demonstrating ability to define and determine precedence of pertinent issues in application of policies and procedures to clinical information and or application to benefit or policy provisions. Perform special projects including reviews of clinical information to identify quality of care issues. To Qualify for This Position, You Will Need Associate’s degree in a job‑related field. Graduate of an accredited School of Nursing. 2 years clinical experience plus 1 year utilization/medical review, quality assurance, or home health, OR 3 years clinical. Working knowledge of word processing software. Ability to work independently, prioritize effectively, and make sound decisions. Working knowledge of managed care and various forms of health care delivery systems. Strong clinical experience to include home health, rehabilitation, and/or broad medical‑surgical experience. Knowledge of specific criteria/protocol sets and the use of the same. Good judgment skills. Demonstrated customer service, organizational, oral and written communication skills. Ability to persuade, negotiate, or influence others. Analytical or critical thinking skills. Ability to handle confidential or sensitive information with discretion. Microsoft Office. Required License and Certificate: An active, unrestricted RN license from the United States and in the state of hire, or an active compact multistate unrestricted RN license as defined by the Nurse Licensure Compact (NLC). What We Prefer You Have Utilization Review / Medical Review experience. MCS System Knowledge. Medicare Part B knowledge. CMS Knowledge. Knowledge of claims systems. Ability to effectively use Microsoft Office applications, such as Word, PowerPoint and Excel. Coding experience. What We Can Do for You 401(k) retirement savings plan with company match. Subsidized health plans and free vision coverage. Life insurance. Paid annual leave – the longer you work here, the more you earn. Nine paid holidays. On‑site cafeterias and fitness centers in major locations. Wellness programs and healthy lifestyle premium discount. Tuition assistance. Service recognition. Incentive Plan. Merit Plan. Continuing education funds for additional certifications and certification renewal. Equal Employment Opportunity Statement BlueCross BlueShield of South Carolina and our subsidiary companies maintain a continuing policy of nondiscrimination in employment to promote employment opportunities for persons regardless of age, race, color, national origin, sex, religion, veteran status, disability, weight, sexual orientation, gender identity, genetic information or any other legally protected status. Additionally, as a federal contractor, the company maintains affirmative action programs to promote employment opportunities for individuals with disabilities and protected veterans. It is our policy to provide equal opportunities in all phases of the employment process and to comply with applicable federal, state and local laws and regulations. We are committed to working with and providing reasonable accommodations to individuals with disabilities, pregnant individuals, individuals with pregnancy‑related conditions, and individuals needing accommodations for sincerely held religious beliefs, provided that those accommodations do not impose an undue hardship on the Company. If you need special assistance or an accommodation while seeking employment, please email View email address on click.appcast.io or call View phone number on click.appcast.io with the nature of your request. We will make a determination regarding your request for reasonable accommodation on a case‑by‑case basis. We participate in E‑Verify and comply with the Pay Transparency Nondiscrimination Provision. We are an Equal Opportunity Employer. #J-18808-Ljbffr CGS Administrators LLC